2023-10-02T10:17:09-05:00 2022-12-31 390758449 WIPFLI LLP 1502 LONDON ROAD SUITE 200 DULUTH MN 55812 990 2022-01-01 813565570 INCLUSA INC INCL 8776226700 2801 HOOVER ROAD 3 STEVENS POINT WI 54481 JASON TAYLOR CHIEF FINANCIAL OFFICER 8776226700 2023-10-02 1 JASON TAYLOR 999009999 0 MICHAEL J PETERSON CPA P01833529 2187224705 2023-10-02 2 AAL1 IAL1 2022 2023-04-26 12:10:37Z MARK HILLIKER 2801 HOOVER ROAD 3 STEVENS POINT WI 54481 806731058 0 X WWW.INCLUSA.ORG X 2016 WI IN ORDER TO MAXIMIZE HEALTH OUTCOMES, INCLUSA PROACTIVELY PARTNERS WITH OTHERS TO BUILD VIBRANT AND INCLUSIVE COMMUNITIES THAT OFFER PEOPLE DIGNITY, CHOICE, AND CONNECTIONS. 13 13 1516 11 0 0 8734 6150 695834461 805182768 275535 1525345 0 16795 696118730 806731058 0 0 0 0 90688375 100840442 0 0 0 581100411 695422578 671788786 796263020 24329944 10468038 163276844 206621989 57920743 91562117 105356101 115059872 IN ORDER TO MAXIMIZE HEALTH OUTCOMES, INCLUSA PROACTIVELY PARTNERS WITH OTHERS TO BUILD VIBRANT AND INCLUSIVE COMMUNITIES THAT OFFER PEOPLE DIGNITY, CHOICE, AND CONNECTIONS. 0 0 768382909 805182768 INCLUSA, INC. PROACTIVELY PARTNERS WITH OTHERS TO BUILD A SHARED VISION OF LONG-TERM CARE THAT OFFERS THE PEOPLE WE SERVE CHOICE, CONNECTIONS, AND DIGNITY; FOSTERING FULL PARTICIPATION IN COMMUNITIES. INCLUSA, INC. PROVIDES MEDICAID MANAGED LONG-TERM CARE SERVICES AND SUPPORT TO NEARLY 16,907 ELDERS AND PEOPLE WITH PHYSICAL AND INTELLECTUAL/DEVELOPMENTAL DISABILITIES IN WISCONSIN. 768382909 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 617 0 1516 1 0 0 0 0 0 0 0 0 0 0 0 0 X 13 13 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X JASON TAYLOR 7152041810 2801 HOOVER ROAD 3 STEVENS POINT WI 54481 KEN DAY PRESIDENT 2.00 X X 9600 0 0 JOAN FORDHAM VICE PRESIDENT 1.00 X X 2400 0 0 RON CARNEY SECRETARY/TREASURER 1.00 X X 2400 0 0 BETH ARIMOND DIRECTOR 1.00 X 2400 0 0 KEN CORNISH DIRECTOR 1.00 X 2400 0 0 JOHN HALBEIB DIRECTOR 1.00 X 2400 0 0 TARA JOHNSON DIRECTOR 1.00 X 0 0 0 JOHN KRIESEL DIRECTOR 1.00 X 2400 0 0 LARRY LAEHN DIRECTOR 1.00 X 2400 0 0 GARY RANUM DIRECTOR 1.00 X 2400 0 0 JANIS RIBBENS DIRECTOR 1.00 X 2400 0 0 KAREN LUMB DIRECTOR 1.00 X 2400 0 0 STEVE MCCARTHY DIRECTOR 1.00 X 2400 0 0 MARK HILLIKER CHIEF EXECUTIVE OFFICER 40.00 X 493149 0 50309 KRISTOPHER KUBNICK CHIEF COMMUNITY RESOURCES 40.00 X 283489 0 47510 TIM GARRITY CHIEF INNOVATION OFFICER 40.00 X 355037 0 46814 JOSHUA JANDRAIN CHIEF INFORMATION OFFICER 40.00 X 285087 0 48840 PATRICK HENNEGER CHIEF LEGAL OFFICER 40.00 X 309315 0 48109 JASON TAYLOR CHIEF FINANCIAL OFFICER 40.00 X 317235 0 12200 STACEY WARGOWSKY EXECUTIVE DIRECTOR OF CM S 40.00 X 200055 0 8266 DANA CYRA EXECUTIVE DIRECTOR OF QUAL 40.00 X 186734 0 30033 KATE NORBY EXECUTIVE DIRECTOR OF MEMB 40.00 X 189883 0 30167 JANNA DUFFY EXECUTIVE DIRECTOR OF FINA 40.00 X 211802 0 8457 ERIN SMITH EXECUTIVE DIRECTOR OF CR/P 40.00 X 191912 0 7672 3059698 0 338377 24 0 1 0 WPS 1717 W BROADWAY MADISON WI 53713 ADMINISTRATIVE (TPA) 3687010 RSM US LLP 5155 PAYSPHERE CIRCLE CHICAGO IL 60674 IT CONSULTATION 3677734 MCKESSON MEDICAL-SURGICAL PO BOX 204786 PLYMOUTH TX 75320 MEMBER SUPPLIES 3534261 ELLIS STONE CONSTRUCTION COMPANY 3201 STANLEY ST STEVENS POINT WI 54481 BUILDING CONSTRUCTION 2279304 REM WISCONSIN III INC 2005 W BELTLINE HWY STE 203 MADISON WI 53713 DIRECT CARE WORKFORCE, CRISIS DIVERSION, 1925537 127 6150 6150 CAPITATION FEE REVENUE 624100 753017973 753017973 ROOM AND BOARD REIMBURSEMENT 623000 52164795 52164795 805182768 1525345 1525345 16795 0 16795 16795 16795 806731058 805182768 0 1542140 2335493 1877970 457523 71514224 56708080 14806144 2720518 2136013 584505 18847534 15263264 3584270 5422673 4304921 1117752 157371 157371 123055 123055 5548810 677039 4871771 307572 4925 302647 1140281 769021 371260 4053143 4389543 -336400 2788651 2402573 386078 1706776 1557190 149586 2237732 1347435 890297 528863 374962 153901 DIRECT MEMBER CARE EXPE 676459705 676459705 EMPLOYEE TRAINING 169514 60333 109181 STAFF INCENTIVES 53333 23441 29892 BOARD EXPENSES 43897 43897 103875 26494 77381 796263020 768382909 27880111 0 10950 -4956280 125353960 174293382 17772095 5262460 1121532 1463628 24839302 7158371 11447045 17680931 6966184 6676642 605078 6201226 163276844 206621989 57920743 75939842 10001040 0 5621235 57920743 91562117 X 105356101 115059872 105356101 115059872 163276844 206621989 10468038 -673568 -90699 0 X 0 1 X 1 0 X 42884 49297 47676 8734 6150 154741 624400324 646214344 659084122 695834461 805182768 3430716019 624443208 646263641 659131798 695843195 805188918 3430870760 0 0 0 3430870760 273349 688202 1105773 275535 1542140 3884999 273349 688202 1105773 275535 1542140 3884999 624716557 646951843 660237571 696118730 806731058 3434755759 0.99890 0.00110 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 17500 17500 0 PART II-B, LINE 1: INCLUSA, INC. PAYS ANNUAL ASSOCIATION MEMBERSHIP DUES TO THE NATIONAL MLTSS HEALTH PLAN ASSOCIATION. THE NATIONAL MLTSS ASSOCIATION IS COMPRISED OF A NUMBER OF HEALTH PLANS THAT PROVIDE SUPPORTS TO MEDICARE/MEDICAID POPULATIONS ACROSS THE U.S. THE DUES PAID TO THE ASSOCIATION ON AN ANNUAL BASIS SUPPORT STAFF HIRED BY THE ASSOCIATION TO ADVANCE ITS POLICY AGENDA AND TO CONTRACT WITH OUTSIDE EXPERTS WHO PROVIDE SUPPORT THROUGH POLICY ANALYSIS, MEETING WITH LEGISLATORS AND STAFF MEMBERS AT THE FEDERAL LEVEL, ATTENDING CONFERENCE AND COMMITTEE HEARINGS, DEVELOPING POLICY BRIEFS AND STATEMENTS ALIGNED WITH MLTSS ASSOCIATION GOALS, AND SECURING SUPPORT FROM OTHER LIKE-MINDED ORGANIZATIONS. 274944 274944 6002058 128703 5873355 1957325 1557735 399590 4385607 3622148 763459 12219368 1849785 10369583 17680931 LEASE OBLIGATION 5621235 5621235 X X 0 0 0 0 0 0 0 0 0 MARK HILLIKER CHIEF EXECUTIVE OFFICER 449585 0 40000 0 3564 0 12200 0 38109 0 543458 0 0 0 TIM GARRITY CHIEF INNOVATION OFFICER 322715 0 30000 0 2322 0 12200 0 34614 0 401851 0 0 0 PATRICK HENNEGER CHIEF LEGAL OFFICER 278505 0 30000 0 810 0 12200 0 35909 0 357424 0 0 0 JOSHUA JANDRAIN CHIEF INFORMATION OFFICER 264306 0 20000 0 781 0 11731 0 37109 0 333927 0 0 0 KRISTOPHER KUBNICK CHIEF COMMUNITY RESOURCES 262949 0 20000 0 540 0 10401 0 37109 0 330999 0 0 0 JASON TAYLOR CHIEF FINANCIAL OFFICER 285993 0 30000 0 1242 0 12200 0 0 0 329435 0 0 0 JANNA DUFFY EXECUTIVE DIRECTOR OF FINA 183057 0 28000 0 745 0 8457 0 0 0 220259 0 0 0 KATE NORBY EXECUTIVE DIRECTOR OF MEMB 168594 0 20000 0 1289 0 7675 0 22492 0 220050 0 0 0 DANA CYRA EXECUTIVE DIRECTOR OF QUAL 164755 0 20000 0 1979 0 7541 0 22492 0 216767 0 0 0 STACEY WARGOWSKY EXECUTIVE DIRECTOR OF CM S 179770 0 20000 0 285 0 8266 0 0 0 208321 0 0 0 ERIN SMITH EXECUTIVE DIRECTOR OF CR/P 171612 0 20000 0 300 0 7672 0 0 0 199584 0 0 0 FORM 990, PART VI, SECTION B, LINE 11B THE 990 IS REVIEWED BY THE CHIEF FINANCIAL OFFICER AND THE CHIEF EXECUTIVE OFFICER. A COPY OF THE 990 IS PROVIDED TO THE GOVERNING BODY BEFORE IT IS FILED WITH THE INTERNAL REVENUE SERVICE. FORM 990, PART VI, SECTION B, LINE 12C THE BOARD OF DIRECTORS SHALL ADOPT AND ALWAYS MAINTAIN A WRITTEN CONFLICT OF INTEREST POLICY ("THE POLICY") THAT IS CONSISTENT WITH BEST PRACTICES FOR CHARITABLE ORGANIZATIONS. ALL DIRECTORS, OFFICERS, AND COMMITTEE MEMBERS SHALL SIGN, AS A CONDITION TO SERVING THE CORPORATION IN HIS OR HER RESPECTIVE ROLE, A STATEMENT AGREEING TO BE BOUND BY THE TERMS OF THE POLICY. PURSUANT TO THE POLICY, ANY DIRECTOR, OFFICER, OR COMMITTEE MEMBER HAVING A MATERIAL FINANCIAL INTEREST IN A CONTRACT OR OTHER TRANSACTION PRESENTED TO THE BOARD OF DIRECTORS OR A COMMITTEE THEREOF FOR AUTHORIZATION, APPROVAL, OR RATIFICATION SHALL MAKE A PROMPT, FULL AND FRANK DISCLOSURE OF SUCH PERSON'S INTEREST TO THE BOARD OF DIRECTORS OR COMMITTEE PRIOR TO ITS ACTING ON SUCH CONTRACT OR TRANSACTION. IF THE CONFLICT IS CONFIRMED BY THE BOARD OF DIRECTORS, THE OFFICER OR COMMITTEE MEMBER IS NOT ALLOWED TO PARTICIPATE IN THE DISCUSSION OR VOTE ON THE MATTER. EACH DIRECTOR OF THE BOARD MUST ANNUALLY SIGN A STATEMENT WHICH AFFIRMS SUCH PERSON: (A) HAS RECEIVED A COPY OF THE CONFLICT OF INTEREST POLICY (B) HAS READ AND UNDERSTANDS THE POLICY (C) HAS AGREED TO COMPLY WITH THE POLICY AND, (D) UNDERSTANDS THE CORPORATION IS CHARITABLE AND IN ORDER TO MAINTAIN ITS FEDERAL TAX EXEMPTION IT MUST ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH ONE OR MORE OF ITS TAX-EXEMPT PURPOSES. FORM 990, PART VI, SECTION B, LINE 15 INITIAL OFFICER COMPENSATION WAS ESTABLISHED USING THE SUPPORT OF A CONTRACTED EXPERT IN EXECUTIVE COMPENSATION. THE CONTRACTED EXPERT DEVELOPED SALARY RANGE INFORMATION FOR THE ORGANIZATION'S EXECUTIVES AND PROVIDED COMPENSATION RECOMMENDATIONS TO THE INCLUSA, INC. BOARD OF DIRECTORS. THE BOARD OF DIRECTORS SET THE CHIEF EXECUTIVE OFFICER'S SALARY BASED ON THIS RECOMMENDATION. THE CHIEF EXECUTIVE OFFICER WAS CHARGED WITH SETTING THE COMPENSATION FOR THE REMAINING EXECUTIVES, USING THE RECOMMENDATIONS PROVIDED BY THE CONTRACTED EXPERT. IN SUCCESSIVE YEARS, THE INCLUSA BOARD OF DIRECTORS HAS SET CHIEF EXECUTIVE OFFICER ANNUAL COMPENSATION USING INDUSTRY COMPARISONS AND OTHER MARKET INFORMATION TO AUGMENT THEIR DECISION PROCESS. THE CHIEF EXECUTIVE OFFICER USES SIMILAR INDUSTRY AND MARKET INFORMATION TO MAKE ANY ANNUAL CHANGES TO THE REMAINING EXECUTIVE STAFF MEMBERS. FORM 990, PART VI, SECTION C, LINE 19 INCLUSA MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. ANNOVA INC 2801 HOOVER ROAD UNIT 3 STEVENS POINT WI 54481 842123943 CONSULTING SERVICES WI INCLUSA INC C 371534 708685 1.00000 1 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 1 0 0 ANNOVA INC D 85375 COST ANNOVA INC Q 444561 COST